Otolaryngology Coding Alert

CPT 2001s new modifier -60 (altered surgical field) could be good news for otolaryngologists and their coders. Until now, any procedure that was complex and required additional work and time was coded and billed with modifier -22 (unusual procedural services).

As of Jan. 1, 2001, however, if the procedure is more complex because the otolaryngologist has encountered an altered surgical field, CPT instructs surgeons to use modifier -60.

CPT describes modifier -60 as follows:

Altered Surgical Field: Certain procedures involve significantly increased operative complexity and/or time in a significantly altered surgical field resulting from the effects of prior surgery, marked scarring, adhesions, inflammation or distorted anatomy, irradiation, infection, very low weight (i.e., neonates and small infants less than 10 kg) and/or trauma (as documented in the patients medical record). These circumstances should be reported by adding the modifier -60 to the procedure number or by use of the separate five-digit modifier code 09960.

Many coding specialists like this new modifier because it more clearly explains why the work was more complicated and/or took more time. It also implies additional payment without excessive documentation for situations, such as revisions of prior surgery, where it is clearly called for. But until Medicare and other carriers announce documentation and reimbursement criteria for using the modifier, its value remains questionable.

Meanwhile, otolaryngologists and their coders will need to distinguish between complicated procedures requiring modifier -60 and those that still should be billed using modifier -22.

The description of modifier -60 includes this note:

For unusual procedural services not involving an altered surgical field due to the late effects of previous surgery, irradiation, infection, very low weight (i.e., neonates and infants less than 10 kg) and/or trauma, append the modifier -22 or use the separate five-digit code 09922.

Modifier -22s description also has been amended:

When the service(s) provided is greater than that usually required for the listed procedure, it may be identified by adding modifier -22 to the usual procedure number or by the use of the separate five-digit modifier code 09922. A report may also be appropriate. Note: This modifier is not to be used to report procedure[s] complicated by adhesion formation, scarring, and/or alteration of normal landmarks due to late effects of prior surgery, irradiation, infection, very low weight ... or trauma [see modifier -60 as appropriate].

What Is an Altered Surgical Field?

As of Jan. 1, when the otolaryngologist performs a procedure that requires more work and/or more time, the correct modifier must be chosen if additional payment is sought. To do so, coders need to understand what an altered surgical field is.

The surgical field is the site where the operation is performed. Usually, surgeons encounter a normal surgical field, which means nothing appears to be impeding the surgeons access to the object of the procedure.

For a number of reasons (including those listed in the modifier -60 descriptor), some patients present in the operating room with an altered surgical field. In such cases, the surgeon may need to spend much time and effort just to be able to perform the procedure.

For example, sinus procedures on patients who have had previous sinus surgery can be considerably more difficult to perform and can involve more risk to the patient due to an absence of landmarks. The same applies to many other procedures, including tympanoplasty with mastoidectomy, where the surgical field is completely altered. Because there are no separate revision codes for any of these procedures, using modifier -60 will inform carriers that the procedure was more difficult and additional payment is justified.

Until now, surgeons have attached modifier -22 to gain additional payment for the additional work involved in performing the revision. But because the previous sinus surgery or tympanoplasty with mastoidectomy has altered the surgical field, this procedure should now be appended with modifier -60.

Whenever the otolaryngologist finds that access to the patients original problem is blocked it could be due to scarring or the effects of prior surgery the surgical site has been altered and, therefore, modifier -60 should be used, says Susan Callaway-Stradley, CPC, CCS-P, an independent coding and reimbursement specialist and educator in North Augusta, S.C.

Situations May Still Require Modifier -22

Sometimes, the surgical field may be normal but the otolaryngologist encounters other problems that make the work more complicated and time-consuming, Callaway-Stradley notes.

For example, the otolaryngologist may open the patient to remove a mass, only to discover that the mass is larger and attached to more bones and muscles than is normally the case. Therefore, additional work and time are required to excise it.

The surgeon has reached his or her objective (the site of the mass) but now has problems dealing with it. The surgical field was not altered, so modifier -60 should not be used, but the surgeon can report the additional work or time spent by attaching modifier -22, Callaway-Stradley says.

Similarly, if a patient bleeds excessively due to a bleeding disorder or other reason and the surgeon requires additional time to perform the procedure, modifier -22 should be used to note that additional work was necessary.

Documentation Requirements

Otolaryngologists and other surgical specialists have long complained that an altered surgical field makes a procedure far more difficult (for example, revisions are more complex than the original procedure due to the absence of surgical landmarks). Coders, meanwhile, have noted that modifier -22 either has been ignored by payers or made impractical by documentation requirements that, even when fulfilled, result in little additional payment.

The introduction of modifier -60 appears to be a welcome response to those concerns, says Barbara Cobuzzi, MBA, CPC, CPC-H, an otolaryngology coding and reimbursement consultant and president of Cash Flow Solutions in Lakewood, N.J.

Modifier -60 potentially is very useful because it implies that certain situations are in and of themselves worthy of additional payment and provides a simple way for surgeons performing a revision of prior surgery to indicate. At the same time it explains why the procedure was more difficult than usual, Cobuzzi says. It may allow some revisions that until now I would not have associated with a modifier -22 unless the operative note cited specific problems or concern.

Cobuzzi notes that because the modifier is new, neither HCFA nor private carriers have announced policies or guidelines for its use. Until such guidelines are issued, as of Jan. 1 Cobuzzi recommends using modifier -60 and documenting it exactly as a modifier -22 claim is reported now. Such claims should include:

A copy of the operative report, including a separate paragraph that describes the nature of the altered surgical field encountered; and

A KISS (keep it short and simple) letter that briefly explains in lay terms why additional payment is being sought, including the nature of the problem and the amount of additional time it took the surgeon to complete the procedure.

How payers will respond to the modifier is critical, Cobuzzi says. If the documentation requirements remain the same as those for modifier -22, then there is little point to carving out the altered surgical field procedures. The difference between the two modifiers will amount to little more than hairsplitting, and coders will have the additional burden of determining whether modifier -22 or modifier -60 should be used, with no prospect of additional payment.

There are clues that CPT does not intend the documentation for modifier -60 to be as intense. For example, the modifier does not indicate that time needs to be documented; it states only that the altered surgical field needs to be documented in the operative report.

Reimbursement Considerations

Because modifier -60 should be used when the otolaryngologist operates on a patient with an altered surgical field, a notation at the top of the operative report that indicates, for example, a revision of prior surgery would be an indication for coders to use modifier -60.

But does that mean additional payment will be forthcoming? Cobuzzi supposes that, like modifier -22, modifier -60 is a payment modifier (i.e., correctly using this modifier results in increased payment).

HCFAs final rule for 2001, which was published in the Nov. 1, 2000, Federal Register, made no mention of modifier -60. Whether it has been valued by the Relative Unit Committee or if its use will require original (or case-by-case) consideration remains unclear.

Modifier -60 would be especially useful if HCFA develops a set fee schedule for its use whereby providers would be paid a predetermined percentage over the basic rate of the procedure when an altered surgical field is encountered. But even if Medicare considers these situations on a case-by-case basis, better documentation by surgeons will result in a greater number of payments that exceed managed-care and HCFA fee schedules, she says.

Until payers determine adequate payment guidelines, Cobuzzi also reminds coders to ask for additional payment on the claim form. As with modifier -22 claims, payers are not likely to increase payment just because modifier -60 has been attached.